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Case of the Month

<< Back to 2004 Case List

June 2004Replantation Reconsideration?

Fig. 1

June's case of the month deals with a young 12 year old male patient who had a fall from a bike and traumatized his two maxillary central incisors. The left maxillary incisor had been avulsed and replanted by the Pedodontist approximately 2 hours after the incident. The Pedodontist did a good job of replanting and splinting the tooth with orthodontic brackets and an arch wire. The right maxillary incisor was devitalized.

The patient was referred to me about 6 weeks after the accident. The brackets and arch wire were still in place. (Fig.1) Clinical examination of the right central showed it to test non vital but other than the large apex, no other significant radiographic complications appeared to be present. The left central was another story. There was already signs of diffuse resorption on the entire periphery of the root and especially at the apex. I had some serious reservations about the long term prognosis of the left central. Nevertheless, I decided to proceed with treatment of the right central and placed CaOH in the left central to try to arrest the resorption.

The right central was treated without incident. (Fig. 2) Although the apex was quite large, a custom (chloroform dipped) gutta percha cone was used to obtain an impression of the apex and then the case was filled using a warm vertical technique. CaOH paste was placed in the left central incisor and the patient was reappointed in 8 weeks.

Fig. 2 - #11 Treated - #21 CaOH in place

Over the next 18 months, the patient continued to return for dressing changes and the tooth appeared to be ankylosing. The apical resorption was continuing and the outlook was not favorable. I also became concerned because of the patient's obvious tooth size-arch size discrepancy and overjet/overbite/crowding problem.(Figs. 3 & 4) An Ortho consult was indicated because it had not yet been initiated by the referring Dentist. I was considering continuation of treatment of the left central incisor and I wanted to make sure that it was the right treatment plan.

Fig. 3
Fig. 4

I happen to have an Orthdodontist in the building and he was kind enough to briefly examine the photos. He suggested that, at a minimum, the patient would require multiple premolar extractions before the teeth could be properly lined up. I believed that any further orthodontic forces that would be placed on this left central would likely accelerate the external resorption and speed up loss of the tooth. This Orthodontist suggested that the tooth could be used as a space maintainer until such time as it was lost and then replaced with an implant. My concern was that the ankylosis could mean that a surgical extraction would be necessary and that the implant site could be compromised if we left the tooth in the present condition and the extraction was difficult. Perhaps extraction was indicated right away?

Fig. 5 - January 2004 Recall
Fig. 6 - May 2004 Recall

Solution
The patient consulted a second Orthodontist who was to be in charge of Orthodontic treatment. After reading a letter I sent to the referring dentist explaining my concerns and performing a proper Ortho work-up, he agreed that the prognosis for #21 was grim. Rather than wait until the tooth was lost or ankylosed, he suggested an alternate treatment plan. BOTH central incisors will be extracted and the lateral incisors will be moved to close the diastema. Eventually, veneers will be placed on these laterals to reproduce proper aesthetics and the adjacent Cuspids and premolars will be recontoured to a more pleasing, aesthetically normal appearance.

Rather than continue with treatment and incur needless expense, the proper course of action was to seek the consultation of other specialties in a team approach. Although it is regrettable that these teeth will be lost, the most important aspect of the case is that a definitive treatment plan is established long before the case reaches an unmanageable or crisis stage.